Legislation/Regulation > Sentinel Event Alerts

As health information technologies such as computerized provider order entry are implemented more widely, awareness of the unintended consequences of these technologies has increased. Both electronic medical records and computerized order entry have been associated with significant problems relating to altered workflow and communication patterns. This sentinel event alert from the Joint Commission reviews the types of adverse events associated with information technology and gives detailed recommendations for how institutions should integrate new technologies. The alert stresses the importance of involving frontline staff in the development and implementation process and also recommends careful postimplementation monitoring for errors and near misses associated with new technology.

Legislation/Regulation > Sentinel Event Alerts

Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.